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FOR OFFICE,USE:- APPLICATION FOR SANITATION PERMIT - --------•---------- ----------• -- Permit No. ---��--- ---- -� - (Complete in Triplicate) ________ __________ This Permit Expires 1 Year From Date Issued Date Issued __ r_. -2t) Application is hereby made to!the San Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION 57d0 C; ,f� a ---------0lll � CENSUS TRACT -------------------------- Owner's Name ---=- -- --- ---- -- - ----- --- - -- Phone - _4-i-- --- p Address Q1�1 -- City Contractor's Name ------ -- -- -- - ------.License # _P? Y/23 Phone � -:� - Installation will serve: Residence,<Apartment House❑ Commercial;❑Trailer Court ;❑ Motel ❑Other . Number of livingunits:_._._ _____'Number of bedrooms ---07 Grinder -_-_-_:_____ Lot Size _ ____________________ Water Supply: Public System and name ------------------------------------ ,- -----------------------------------Private, Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Pat❑ Sandy Loom ❑ Clay Loam ❑ Hardpan ❑ AdobeX Fill Material ------------ If yes, type ---------------------------- G (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT { ] SEPTIC TANK[ ] Size------------------------------ ----------------- Liquid Depth ______________________--- Capacity ------------- - Type -------------------- Material----- ---------------- No. Compartments ------•------------ Distance to nearest: Well ---------------------- ------=-----Foundation -.-------------------- Prop. Line -------------- LINE [ 7 No. of Lines ------------------------ Length of•eachiline__.____________"":__._.__ Total Length _____--__-_______.__..__-- D' Box `_+___..____ Type Filter Material ____________________Depth Filter Material _.____-___-______.____-____________------- Distance to nearest: Well ------------------------ Foundation ------•---------------- Property Line ------------------------ SEEPAGE PIT [ ] Depth ___________________ Diameter _____________._ Number __._______ ---------------- r' � _-_______ Rock Filled Yes ❑ No___ Water Table Depth ------------------------------------------------Rock Size -------------------------------- Distance to nearest: Wel! ----------------------------- -----------Foundation -------------------- Prop. Line _______-__--_____. REPAIR/ADDITION(Prev+Sanitation Permit# --- - -- ---------- ------------------------- Date --------------_------------------_} j Septic Tank (Specify Requirements) ------- f- --- ---------------------------------- - r ----- -- 'r Disposal Field (Specify Requirements) -------- ---- ---------- _ --- -------------------------------- - 4' F - ------ ---- .-�] � ' (Draw exi tin Wd re uir dition on reverse side} I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, State Laws, land Rules and Regulations of the San Joaquin Local Health District. Home owner or licen- sed agents signature certifies.the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to bec a su ject to,Workn iso Compensation laws of California." I Signed } .0l ` - ------- Owner By --------------------------- ----------------- Title ---------------- --------- --------------------------------------------- {If other than owned FOR DEPARTM NT USE ONLY APPLICATION ACCEPTED BY _._ DATE --------------------------------- BUILDING PERMIT ISSUED -------- ------- - - F---------------------------------------- _DATE - ----- -------------------------- ADDITIONAL COMMENTS ------------------- ------------------------------------------------------ ------------------------------------- -------------------------------------------------------------------------------- -------------------------------------------- --- --- -- --- - - - - - - --- ---Final Inspection by_ _______ t t -^] a - - - - ----- :Date ` SAN JOAQUIN LOCAL HEALTH D15TRlCT E. H. 9 1-'6B Rev. 5M ,/